Provider Demographics
NPI:1760569669
Name:CONNER, ANDREA H (LPA)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:H
Last Name:CONNER
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10249 TIMBER RIDGE CT SE
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-8536
Mailing Address - Country:US
Mailing Address - Phone:910-599-4857
Mailing Address - Fax:910-762-1195
Practice Address - Street 1:1612 DOCTORS CIR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7406
Practice Address - Country:US
Practice Address - Phone:910-762-1190
Practice Address - Fax:910-762-1195
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2328103TC0700X, 101YM0800X, 103TC2200X, 103TB0200X, 103TP2701X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107336Medicaid